The most common orthopedic condition for which professional medical treatment is sought is lower back pain. Although many factors may be responsible for causing lower back pain, a principal factor is damage or degeneration of an intervertebral spinal disc resulting in impingement on the nerve system, specifically the spinal cord, located within the spine. Such impingement may result in, for instance, loss of mobility, urinary and fecal incontinence, and sciatica or pain experienced in the extremities.
Damage to or degeneration of a spinal disc can result from a number of factors such as abuse or age. The disc itself is composed primarily of an annulus and a nucleus contained therein. The annulus is a fibrous annular piece that attaches to the adjacent vertebrae and contains the nucleus, which is in turn a gel-like viscous material capable of shock absorption and flowable to permit poly-axial rotation and resilient compression of the vertebrae and spine. Most frequently, disc degeneration results from damage occurring to the annulus such that the flowable nucleus material may leak or seep out of the annulus. Disc degeneration also can occur in other ways, such as by being deprived of nutrient flow leading to a dried and susceptible to damage disc. Because the nuclear material is flowable, extensive damage to the annulus is not necessary for leakage to occur.
Currently, approaches to treatment of spinal problems directly effecting the spinal cord are numerous. For instance, immobilization and high doses of corticosteroids may be employed. The dominant surgical procedures for treatment of these problems are spinal fusion and discectomy. Fusion is a method where adjacent vertebrae are immobilized so that they permanently secure to each other by having bone growth between and to the vertebrae, while discectomy involves removal of a portion or an entirety of a spinal disc.
However, the current practice of each of these procedures typically has certain limitations. With fusion, making a portion of the spine generally rigid produces a reduction in mobility, and drastically alters normal load distribution along the spinal column. Due to these factors, the non-fused portions of the spine experience stress and strain that are significantly increased over normal physiological motions. The increased stress and strain on the non-fused portions may lead to accelerated disc degeneration of the non-fused portions, particularly the adjacent levels of the spine.
Discectomy is effective for relieving sciatic pain by removing the damaged or herniated disc tissue compressing the spinal nerves. However, current discectomy often may lead to a reduction of the disc space between adjacent vertebrae, as well as instability in the affected portion of the spine. Such long-term effects with current discectomy often result in further surgery several years after the initial discectomy surgery.
A recent, though not new, development for spinal surgery of this type is a procedure known as disc arthroplasty for restoring or reconstructing the disc using a prosthesis to replace a portion or entirety of the damaged disc. The primary objective of disc arthroplasty is to restore or maintain the normal disc anatomy and functions, while addressing and treating the causes of the pain. However, little success has been experienced with prosthetic disc implants due to the complexity of the natural disc structure and biomechanical properties of a natural spinal disc. As used herein, the term natural refers to normal tissue including portions of the spine and the disc.
Two types of prostheses for disc arthroplasty are currently believed to merit further development by medical science and research. One type is a total disc prosthesis, or TDP, where the entire spinal disc is replaced after radical discectomy. A typical TDP includes structures that together mimic the properties of a natural disc.
The other type is a disc nucleus prosthesis, or DNP, that is used to replace only the nucleus of a spinal disc after a nucleotomy while retaining the annulus of the disc and, possibly, the end plates intact. As discussed above, failure of the natural disc does not require extensive damage to the annulus, and the annulus would often be capable of retaining a non-flowing prosthetic nucleus. Implantation of an DNP involves clearing of the natural nucleus from the annulus through the procedure known as nucleotomy, and inserting the DNP within the annulus. Accordingly, disc nuclear prostheses (DNPs) are typically smaller and require less extensive surgery than TDPs do.
In using disc implants, there are a number of issues with currently known TDPs and DNPs that attempt to mimic the biomechanical properties of a natural intervertebral disc. Some implants have been designed that provide shock absorption similar to a natural disc. However, these discs have typically been found incapable of maintaining structural integrity over the cyclic load life required of a disc that may be employed for 20 or more years. An early attempt at providing the polyaxial movement and rotation of the spine involved replacing the disc with a metal ball. Undesirably, loading between the ball and the end plates was highly concentrated such that bone subsidence caused the vertebrae to collapse around the ball.
Another issue is implant extrusion, defined as the tendencies for an implant not to remain seated, and for the implant to back out of its intended seat. To prevent this, many designs for disc implants attempt to secure to the end plates of the vertebrae by providing securement features on the implant. The securement features are usually a system of prongs or spikes or other physical protrusions designed to embed in the vertebrae. This, alone, violates the integrity of the end plates to a degree where revision surgery is limited, possibly to spinal fusion for immobilizing the spinal segment and fusing the vertebrae with posterior pedicle instrumentation. Violation of the vertebrae by the securement may cause bleeding, or calcification of the end plate, either of which can result in pain, loss of mobility, necrosis, or deterioration of any implant device. In mating the implant with the end plates, stress concentrations may result due to contour mismatch, such as occur with the above-described implant ball. Thus, positioning of the implant, particularly an implant which utilizes such protrusions, must be performed carefully. To diminish these high stress concentrations or points on the vertebrae, the implant will often have top and bottom plates that cover respective vertebra and often have securement features found on the plates to fix the plates to the vertebrae. In this manner, the stress or forces are distributed thereacross.
Most implants are units that are implanted as a whole. Therefore, the adjacent vertebrae must be sufficiently distracted for the effective size of the implant including the top and bottom plates, which can be significantly increased when fastening protrusions are included. This requires greater invasiveness, which complicates surgery and leads to greater time for recovery and post-surgical pain. Furthermore, this often destroys any remaining utility for the annulus as a large incision must be made, in the event it is even retained. As the annulus does not heal well and suturing the annulus is difficult due to its tissue properties, the ability of the annulus to retain the implant is diminished if not eliminated, and implant extrusion often is not prevented by the annulus.
Some implants that are inserted as a whole utilize a bladder or balloon-like structure. These implants may be inserted in a collapsed state, and then inflated once in situ. However, these implants typically rely on a structure that is entirely resiliently deformable. Therefore, these implants typically are limited to providing shock absorption, while not providing range of motion with high-cyclic loading or sufficient support.
Most spinal disc procedures require an anterio-lateral approach to the surgical site. More specifically, spinal disc implants typically have a size roughly that of the natural spinal disc. In order to evacuate the disc space and implant the prosthetic device, space is required. Because of the geometry and structure of a vertebra, a natural disc, and an artificial disc implant, posterior surgical procedures do not typically permit the access required for evacuation of the disc space and implantation of the prosthetic device. Furthermore, for an anterior-lateral approach to the surgical site, a general surgeon's service must be employed, typically in conjunction with an orthopedic surgeon or neurosurgeon, or both. Therefore, an implant device that may be implanted in multiple surgical approaches is desirable.
Less extensive surgery is required for a DNP than for a TDP. A DNP replaces only part of the disc. Implantation of most DNPs with pre-formed dimensions requires a 5-6 mm, or larger, incision in the annulus for implantation. Some DNPs, such as those utilizing in situ curable polymers, may be performed percutaneously. In any event, implantation of a DNP requires minimal disc tissue resection, and can avoid violating the end plates of the vertebrae for securing. Moreover, recovery and post-surgical pain are minimal due to the minimal invasiveness of the procedure, and interbody fusion remains a viable revision surgery,
It has been found herein that it is particularly important to restore the normal range of motion of the spine. Specifically, it has been found to be more important to provide flexion/extension, lateral bending, and axial rotation of the spine, than it is to provide the compressive modulus of elasticity. More particularly, it is believed that failure to provide the normal range of motion has the deleterious effects, as discussed above, of spinal fusion. In contrast, it is believed that the loss of compressive elasticity in that region may be borne by the other natural spinal discs. As the implant needs to restore or maintain disc height, it should withstand a significant amount of compressive load in the proper physiological manner so end plate damage is not induced that may lead to pain and implant subsidence.
A number of attempts have been made at artificial discs, each presenting deficiencies. Some procedures and devices rely on lateral or anterior surgical procedures, which are highly invasive and traumatic and which carry high surgical risk.
Accordingly, there has been a need for an improved disc implant for mimicking the biomechanical properties of a natural disc.